ICU, eFocus/eICU, and Interdisciplinary Care Rounds … · Impact on Ventilator Associated...
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ICU, eFocus/eICU, and Interdisciplinary Care Rounds (IDCR) Impact on Ventilator Associated Pneumonia (VAP) Jodeena M. Kempnich, RN, MSN and Kimberly E. Sieck, RN, MSN, CCRN-E STRATEGY and IMPLEMENTATION IDCR education is included in orientation to all new ICU RNs in the Alegent Health System. The IDCR process will be communicated to patients & family on admission to ICU. The IDCR will be held at the patient’s bedside. The IDCR team is lead by the patient’s RN and includes the eFocus/eICU RN. The eFocus/eICU RN will prompt the IDCR team to focus on the ventilator bundle: Elevate head of bed, VTE prevention, Stress Ulcer prevention, Sedation Vacation, and Daily Ventilator Weaning. The eFocus/eICU RN will transcribe the patient’s plan of care and print it in the ICU unit to be placed in the patient’s medical record. The patient’s RN will write the patient’s daily goal(s) on the white board in the patient room. The eFocus/ eICU has the capability to run a real-time Vent Bundle Report which includes the 5 elements listed above. This report is faxed and communicated to the bedside team at least twice a shift. TOOLS / RESOURCES Top left to right: Evidence Based Orders • Ventilator Managment Protocol (front and back of form) • Sedation (front and back of form) Middle left to right: ICU Whiteboard Patient Careplan (front and back of form) Bottom left to right: Ventilator Bundle Daily Managment Report PURPOSE ICU staff must keep patients safe and protect them from harm as VAP is a preventable medical condition. This can be done by creating a culture of ownership and responsibility of the bedside clinician. NO VAP is acceptable. SIGNIFICANCE VAP is a hospital-acquired infection increasing morbidity up to 50% and raises the cost of health care with additional costs estimated between $5,000 and $20,000 per diagnosis. VAP can be prevented with simple measures but the implementation of putting the measures into practice can be absent. OBJECTIVES 1. Discuss the role of ICU, eFocus/eICU and Interdisciplinary Care Rounds and the impact on Ventilator Associated Pneumonia (VAP). 2. Provide support for evidence-based nursing practice in eliminating VAP. eFocus/eICU Description A remote, centralized, Intensivist-led care team that uses enabling technology to continuously monitor, assess and intervene in support of the on-site caregivers. eFocus uses information technology tools that improve workflow and communication as well as assists in standardizing care processes and track results. 0 1 2 3 4 5 6 7 8 9 10 MCB IMC LKS MDL BMMC FY10 Annual Quarter4 Quarter 3 Quarter 2 Quarter1 VAP LATE PEER 1000 VENT DAYS NHSN Benchmark < 15 beds NHSN Benchmark > 15 beds Baseline Data FY10 IDCR EVALUATION Data collected includes compliance of each Vent Bundle element as well as the number of VAP for each month. The data is communicated to the system Critical Care Committee and Patient Safety and Quality Council as well as the on-site Critical Care Committees and Quality Councils. IMPLICATIONS FOR PRACTICE Real time assessment, reports, and notification of the defects drives the success for the elimination of VAP. The access to the real time reports help to identify best practices, establish standardize processes, and learn from each other’s experiences. 0 1 2 3 4 5 6 7 8 9 10 MCB IMC LKS MDL BMMC Quarter1 VAP LATE PEER 1000 VENT DAYS NHSN Benchmark > 15 beds NHSN Benchmark < 15 beds FY11 First Quarter Admit Diagnosis: Cardiovascular: Sepsis, renal/UTI (including bladder) Code Status: Full therapy Managing Physician: Admitting Physician: DAILY AND PATIENT GOALS Daily Goals/Safety Risks/Discharge Requirements: Infection/Labs: Active: Absence of sepsis (10/06/2010 14:28) Fluid Balance/Treatments: Active: Urine output >30 ml/hr (10/06/2010 14:28) Pulmonary: Active: Pulse oximetry within ordered parameters (10/06/2010 14:28) PATIENT-FAMILY Baseline Status: Prognosis: Health Care Proxy/Contact Info: End-of-Life Discussion: Psychosocial Status: Critical Care Discharge/Transfer Planning: Status: Not ready for discharge Discharge Issues: Frequent Suctioning; Respiratory Issue Disposition: Step-down unit Plan: Continuing care needs assessment ACTIVE THERAPIES Sedation: Continuous infusion - with daily holiday Analgesia: Parenteral - bolus prn Airway: Intubated/oral ETT Ventilation: Ventilated - with daily extubation evaluation Volume Status: Unknown Infectious Disease: DVT Prophylaxis: Compression devices Stress Ulcer Prophylaxis: Proton pump inhibitor Ordered Protocols: Sepsis bundle; Ventilator bundle; Ventilator wean NUTRITION Route-Status: NPO Report Run Date: 10/06/2010 14:38 Page 1 of 2 Release 3.7.1 Care Plan Permanent Medical Record Patient: BUNDLE, SEPSIS DOB: Unit Admission Date: 10/06/2010 13:58 Saved/Validated: on 10/06/2010 14:38 by Sieck, Kim (RN) Bergan Mercy Medical Center - BMMC-ICU (Bed ID: 10) PID: 55555 Account #: SUPPORTIVE CARE Planned Procedures: Activity: HOB 30 degrees Pressure Ulcer Treatment: Safety/Restraints: Safety: Assess fall risk; Precaution-Aspiration Restraints: Soft limb; Left wrist; Right wrist Report Run Date: 10/06/2010 14:38 Page 2 of 2 Release 3.7.1 Care Plan Permanent Medical Record Patient: BUNDLE, SEPSIS DOB: Unit Admission Date: 10/06/2010 13:58 Saved/Validated: on 10/06/2010 14:38 by Sieck, Kim (RN) Bergan Mercy Medical Center - BMMC-ICU (Bed ID: 10) PID: 55555 Account #: Bergan Mercy Medical Center - BMMC-ICU All Current Census Patients Bed Patient Care Plan Today DVT Rx SUP Rx Sed. Hol. SB Trial HOB > 30 (within 12 hrs) Comment Ventilated Patients 02 PATIENT, NEW PID: 11111 Acct. #: 10/06 14:07 03 CLIENT, SURGICAL PID: 22222 Acct. #: 10/06 14:14 06 NURSE, NANCY PID: 33333 Acct. #: 10/06 14:20 08 OFFICE, DOCTOR PID: 44444 Acct. #: 10/06 14:25 10 BUNDLE, SEPSIS PID: 55555 Acct. #: 10/06 14:30 12 TRANSFER, FLOOR PID: 66666 Acct. #: = No Current Data CI = Contraindicated NA = Not Applicable Report Run Date: 10/07/2010 09:59 1 of 2 Release 3.7.1 ©2009 Philips VISICU - Confidential and Proprietary Permission to reproduce is required. Philips VISICU retains all rights to the information provided provided, including, but not limited to, the right of distribution. Vent Bundle Alegent Health Current Census as of: 10/07/2010 09:59 PHARMACY STAT Evidence Based Care (po0010) PHYSICIAN ORDERS / PROGRESS NOTES CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.” DATE/ TIME ORDERS DATE/ TIME PROGRESS NOTES/CONSULTATION VENTILATOR MANAGEMENT PROTOCOL Revised: 5/10 - Next Review: 5/11 Page 1 of 2 Ventilator Initiation ; Mode: A/C. ; Rate: 10-12 bpm. ; VT = 5-8 ml/kg ideal body weight. ; PEEP: 5 cm H2O unless contraindicated (see right side). ; FiO2: 100% - may wean for SaO2 ≥90% after initial ABG. ; ABG 30 minutes after ventilator is initiated. Call results to physician. ; Insert nasogastric/orogastric tube and place to low intermittent suction. ; CXR after intubation if not already done. ; Daily CXR while intubated. ; Insert indwelling urinary catheter. Ventilator Management ; Utilize SIMV with pressure support if patient’s clinical status warrants. ; Adjust VT within the range of 5-8 ml/kg ideal body weight. ; Adjust rate to maintain pH >7.3 and <7.5. ; Adjust PEEP up to 7.5 cm H2O for oxygenation purposes. ; Pressure support may be adjusted to regulate spontaneous VT to maintain an acceptable work of breathing – limit 20 cm H2O. ; ABGs will be drawn on patients with a realized change in VE of 20% or more. ; Physician must be notified of all patient status changes. Ventilator Bundle Orders ; Elevate head of bed to 30 degrees. If head elevation is contraindicated, place in reverse Trendelenburg if type of bed allows this position. ; Oral care every 2 to 4 hours. ; Respiratory Therapy and Nursing to coordinate sedation vacation times with an extubation readiness assessment and weaning trials. If patient is on a neuromuscular blocking agent, turnoff the neuromuscular blocking agent at a minimum of every 24 hours ensure that a minimum of 4/4 twitch level is achieved. If this is not achieved, notify physician. 87018 v4 (Continued on Page 2) Ideal Body Weight Calculations: IBW Male = 50 kg + (2.3 kg x Inches > 5 ft) IBW Female = 45.5 kg + (2.3 kg x Inches > 5 ft) Contraindications to PEEP (Egans fundamentals of Respiratory Care) ►Increased Intracranial Pressure ►Pneumothorax that has not been treated ►Bronchopleural fistula ►Low Systolic blood pressure PHARMACY STAT Evidence Based Care (po0010) PHYSICIAN ORDERS / PROGRESS NOTES CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.” DATE/ TIME ORDERS DATE/ TIME PROGRESS NOTES/CONSULTATION VENTILATOR MANAGEMENT PROTOCOL Page 2 of 2 Stress Ulcer Medication Options Famotidine (Pepcid) 20 mg IV every 12 hours. (Pharmacy to adjust dose for renal function.) Esomeprazole (NexIUM) 40 mg dilution with 5 ml NS IV push over at least 3 minutes every 24 hours. Sucralfate (Carafate) 1 gram Nasogastric, Orogastric or PEG tube every 6 hours. • Place Thrombosis Prophylaxis order (doc #83629) on chart for Physician review and consideration. Ventilator Weaning Protocol • FiO2 will always be weaned to a minimum of 30% unless there is a documented contraindication. • At 0700 or when clinically appropriate, mechanically ventilated patients not meeting any of the exclusionary criteria will be placed on CPAP-5 cm with PS +5 cm H2O. • Titrate FiO2 per O2 protocol. The trial should be continued for at least 2 hours and no less than 1 hour as indicated, or until any of the failure criteria are met. Patients failing the breathing trial should be put back on their previous mode of ventilation. • Weaning parameters will be checked per protocol, and the results will be entered into the electronic medical record for physician review. • When extubation criteria are met, notify physician. • Arterial blood gases will be obtained at the discretion of the physician or respiratory therapist responsible for the spontaneous breathing trial. Ordering MD/DO/NP/PA Signature Date Time 87018 v4 Warning Statement Proton Pump Inhibitor interaction with PlaVIX Please assess patients on proton pump inhibitors and clopidogrel (PlaVIX) for possible drug interaction. If there is a high risk of GI bleed consider the use of pantoprazole (ProtoNIX) as an option for stress ulcer prevention. Exclusionary Criteria for Ventilator weaning • Paralytics or deep sedation (modified Ramsay scale 4- 5). • Requiring >10 cm H2O PEEP or an FiO2>50% to keep O2 sat >88%. • Hemodynamic instability. • Unstable cardiac rhythms. • Patient with respiratory rate >30/minute while receiving a mandatory rate. • Minute volume of >15 L/minute. • Cardiogenic shock. • Acute Myocardial Infarction. • Lactic acidosis. Failure Criteria • Obvious respiratory distress (apnea, failure to trigger vent, paradoxical respiratory movement, diaphoresis, agitation). • Respiratory rate >32/minute for 10 minutes or longer. • Tachycardia >150/minute or an increase of >20% from baseline for >10 minutes, or new onset arrhythmia. • Hypotension (SBP <90 mmHg) or a drop in blood pressure of more than 20% from baseline. • Apnea beyond the first 5 minutes of the trial. • SaO2 <88% despite a FiO2 of >50%. MODIFIED RAMSAY SCALE 1 Patient anxious, agitated, or restless 2 Patient cooperative, oriented, and tranquil 3 Patient responds to commands only 4 Patient responds to gentle shaking 5 Patient responds to noxious stimulus 6 Patient has no response to firm nail by pressure or other noxious stimuli PHARMACY STAT Evidence Based Care (po0010) PHYSICIAN ORDERS / PROGRESS NOTES CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.” DATE/ TIME ORDERS DATE/ TIME PROGRESS NOTES/CONSULTATION SEDATION FOR MECHANICALLY VENTILATED PATIENTS Revised: 5/10 - Next Review: 5/11 Page 1 of 2 ; Patient must be intubated and mechanically ventilated to use this order set. Maintain appropriate mandatory minimum minute ventilation. ; Assure airway is secured and ventilator alarms are functioning. ; Obtain baseline neurological assessment prior to initiating sedation. ; Elevate head of bed 30 degrees. If head elevation is contraindicated, place in reverse Trendelenburg if type of bed allows this position. ; Place Ventilator Management Protocol on chart for Physician review and consideration (Doc #87018). ; Place Thrombosis Prophylaxis order (Doc #83629) on chart for Physician review and consideration. ; Insert orogastric (preferred)/nasogastric tube unless otherwise directed and place to low intermittent suction if not contraindicated (e.g. facial trauma, bleeding risk or previous bariatric surgery). ; Vital signs per nursing unit protocol and every 15 minutes if titrating propofol (Diprivan). ; Continuous pulse oximetry. ; Measure and record weight now and every day. ; Pressure reduction sleep surface. ; Oral care every 2-4 hours. ; Assess Ramsay Score every 1 hour until desired effect, then every 4 hours. Desired score: __________ (recommended score of 2-4). ; Awaken patient daily to assess neurologic status. Coordinate sedation vacation with Respiratory Therapy for weaning trial. Laboratory ; Obtain baseline serum triglyceride level prior to the initiation of propofol (Diprivan). ; Obtain serum triglyceride every 72 hours while on propofol (Diprivan) therapy times 3 draws. ; Titrate sedatives to maintain Ramsey score of 2. Use the lowest possible dose that maintains desired sedation level, which may mean no sedatives at times. 87017 v5 (Continued on Page 2) MODIFIED RAMSAY SCALE 1. Patient anxious, agitated, or restless 2. Patient cooperative, oriented, and tranquil 3. Patient responds to commands only 4. Patient responds to gentle shaking 5. Patient responds to noxious stimulus 6. Patient has no response to firm nail pressure or other noxious stimuli PHARMACY STAT Evidence Based Care (po0010) PHYSICIAN ORDERS / PROGRESS NOTES CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.” DATE/ TIME ORDERS DATE/ TIME PROGRESS NOTES/CONSULTATION SEDATION FOR MECHANICALLY VENTILATED PATIENTS Page 2 of 2 Sedative medication LORazepam (Ativan) mg IV push q.1h. as needed for agitation (recommended range 1-3mg). OR Propofol (Diprivan) initiate at 5 mcg/kg/minute. Titrate by 5-10 mcg/kg every 5-10 minutes until desired sedation level is achieved. (Maximum of 100 mcg/kg/minute). If BIS monitoring is ordered, titrate to BIS value of 40-60. Analgesic medication Morphine Sulfate mg IV push q.1h. as needed for pain (recommended range 1-5 mg. max dose 10 mg) OR FentaNYL mcg IV q.1h. as needed for pain (recommended range 25-100 mcg). Delirium Order Haloperidol (HALdol) Bolus 1-5mg IV push. Assess agitation level after 20 minutes. If loading dose ineffective, increase dose by 1-5 mg every 20 minutes until desired effect, to a maximum of 15 mg. Stress Ulcer Medication Options: Famotidine (Pepcid) 20 mg IV every 12 hours. (Pharmacy to adjust dose for renal function.) Esomeprazole (NexIUM) 40 mg diluted with 5 ml 0.9% NaCl IV push over at least 3 minutes every 24 hours. Sucralfate (Carafate) 1 gram nasogastric, orogastric or PEG tube every 6 hours. Other . ___________________________________________ Ordering MD/DO/NP/PA Signature Date ________________ Time 87017 v5 Consider re-evaluating the use of propofol (Diprivan) daily. Consider using FentaNYL as a first option in the hemodynamically unstable patient. Warning Statement Proton Pump Inhibitor interaction with PlaVIX Due to literature reports of potential drug-drug interactions between PPIs and PlaVIX it is recommended to use a H2-Receptor Antagonist such as Pepcid (Famotidine), or Carafate for stress ulcer prophylaxis in patients who are receiving PlaVIX. Alegent Health Daily ICU Interdisciplinary Plan of Care Date: ________ Nurse: _____________________ R.T.:______________________ Primary MD: _____________________ Consulting MD:___________________ Consulting MD:________________________ Admission weight_________ Height_________ Expected Length of Stay___________ Transfer Plan____________________ From__________ Return to_________ Independent Assistance DNR status______________ Family Conference Date______________ #1 Family Contact________________ Patients #1 Safety Risk Today’s Goals Interventions 1. 2. 3. 4. 5. Glucose Control Glucose on Arrival to ICU ___________ Last Glucose_________ Type of Coverage________________ Nutrition___________________ □ DVT prophylaxis □ Stress ulcer prevention □ PT/OT/speech consult □ Planned field trips Core Measures □ PN □ CHF □ Acute MI □ Stroke Vent Bundle: □ Head of Bed >30 □ Oral Care Q 2-4 hr □ Peptic Ulcer Prophylaxis □ DVT prophylaxis □ Sedation Vacation and readiness to wean every 24hours Time of Sedation Vacation_________ Outcome of Sedation Vacation______ Vent Day __________ Central Line Bundle: □ Insertion Date ______ □ Central line Day_____ □ Last Dressing Change date___________ □ Last Tubing Change____________ □ Central Line insertion check list used on Insertion Alegent Health is a faith-based health ministry sponsored by Catholic Health Initiatives and Immanuel. Photos left to right: IDCR at eFocus and IDCR at ICU bedside.
Transcript of ICU, eFocus/eICU, and Interdisciplinary Care Rounds … · Impact on Ventilator Associated...
ICU, eFocus/eICU, and Interdisciplinary Care Rounds (IDCR) Impact on Ventilator Associated Pneumonia (VAP)
Jodeena M. Kempnich, RN, MSN and Kimberly E. Sieck, RN, MSN, CCRN-E
STRATEGY and IMPLEMENTATIONIDCR education is included in orientation to all new ICU RNs in the Alegent Health System. The IDCR process will be communicated to patients & family on admission to ICU. The IDCR will be held at the patient’s bedside. The IDCR team is lead by the patient’s RN and includes the eFocus/eICU RN. The eFocus/eICU RN will prompt the IDCR team to focus on the ventilator bundle: Elevate head of bed, VTE prevention, Stress Ulcer prevention, Sedation Vacation, and Daily Ventilator Weaning. The eFocus/eICU RN will transcribe the patient’s plan of care and print it in the ICU unit to be placed in the patient’s medical record. The patient’s RN will write the patient’s daily goal(s) on the white board in the patient room. The eFocus/eICU has the capability to run a real-time Vent Bundle Report which includes the 5 elements listed above. This report is faxed and communicated to the bedside team at least twice a shift .
TOOLS / RESOURCES
Top left to right: Evidence Based Orders
• Ventilator Managment Protocol (front and back of form)
• Sedation (front and back of form)
Middle left to right:
ICU Whiteboard
Patient Careplan (front and back of form)
Bottom left to right:
Ventilator Bundle Daily Managment Report
PURPOSEICU staff must keep patients safe and protect them from harm as VAP is a preventable medical condition. This can be done by creating a culture of ownership and responsibility of the bedside clinician. NO VAP is acceptable.
SIGNIFICANCEVAP is a hospital-acquired infection increasing morbidity up to 50% and raises the cost of health care with additional costs estimated between $5,000 and $20,000 per diagnosis. VAP can be prevented with simple measures but the implementation of putting the measures into practice can be absent.
OBJECTIVES 1. Discuss the role of ICU, eFocus/eICU and Interdisciplinary Care Rounds and
the impact on Ventilator Associated Pneumonia (VAP).
2. Provide support for evidence-based nursing practice in eliminating VAP.
eFocus/eICU DescriptionA remote, centralized, Intensivist-led care team that uses enabling technology to continuously monitor, assess and intervene in support of the on-site caregivers. eFocus uses information technology tools that improve workflow and communication as well as assists in standardizing care processes and track results.
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Baseline DataFY10
IDCR
EVALUATIONData collected includes compliance of each Vent Bundle element as well as the number of VAP for each month. The data is communicated to the system Critical Care Committee and Patient Safety and Quality Council as well as the on-site Critical Care Committees and Quality Councils.
IMPLICATIONS FOR PRACTICEReal time assessment, reports, and notification of the defects drives the success for the elimination of VAP. The access to the real time reports help to identify best practices, establish standardize processes, and learn from each other’s experiences.
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Admit Diagnosis: Cardiovascular: Sepsis, renal/UTI (including bladder)
Code Status: Full therapy
Managing Physician: Admitting Physician:
DAILY AND PATIENT GOALS
Daily Goals/SafetyRisks/DischargeRequirements:
Infection/Labs: Active: Absence of sepsis (10/06/2010 14:28)
Fluid Balance/Treatments: Active: Urine output >30 ml/hr (10/06/2010 14:28)
Pulmonary: Active: Pulse oximetry within ordered parameters (10/06/2010 14:28)
PATIENT-FAMILY
Baseline Status:
Prognosis:
Health Care Proxy/Contact Info:
End-of-LifeDiscussion:
Psychosocial Status:
Critical Care Discharge/TransferPlanning:
Status: Not ready for discharge
DischargeIssues:
Frequent Suctioning; Respiratory Issue
Disposition: Step-down unit
Plan: Continuing care needs assessment
ACTIVE THERAPIES
Sedation: Continuous infusion - with daily holiday Analgesia: Parenteral - bolus prn
Airway: Intubated/oral ETT Ventilation: Ventilated - with daily extubation evaluation
Volume Status: Unknown
Infectious Disease:
DVT Prophylaxis: Compression devices Stress Ulcer Prophylaxis:
Proton pump inhibitor
Ordered Protocols: Sepsis bundle; Ventilator bundle; Ventilator wean
NUTRITION
Route-Status: NPO
Report Run Date: 10/06/2010 14:38 Page 1 of 2 Release 3.7.1
Care Plan Permanent Medical Record
Patient: BUNDLE, SEPSIS DOB:
Unit Admission Date: 10/06/2010 13:58 Saved/Validated: on 10/06/2010 14:38 by Sieck, Kim (RN)
Bergan Mercy Medical Center - BMMC-ICU (Bed ID: 10)
PID: 55555 Account #:
SUPPORTIVE CARE
Planned Procedures:
Activity: HOB 30 degrees
Pressure Ulcer Treatment:Safety/Restraints: Safety: Assess fall risk; Precaution-Aspiration
Restraints: Soft limb; Left wrist; Right wrist
Report Run Date: 10/06/2010 14:38 Page 2 of 2 Release 3.7.1
Care Plan Permanent Medical Record
Patient: BUNDLE, SEPSIS DOB:
Unit Admission Date: 10/06/2010 13:58 Saved/Validated: on 10/06/2010 14:38 by Sieck, Kim (RN)
Bergan Mercy Medical Center - BMMC-ICU (Bed ID: 10)
PID: 55555 Account #:
Bergan Mercy Medical Center - BMMC-ICUAll Current Census Patients
Bed Patient Care Plan Today
DVT Rx SUP Rx Sed. Hol. SB Trial HOB > 30(within 12 hrs)
Comment
Ventilated Patients02 PATIENT, NEW
PID: 11111Acct. #:
10/06 14:07
03 CLIENT, SURGICALPID: 22222Acct. #:
10/06 14:14
06 NURSE, NANCYPID: 33333Acct. #:
10/06 14:20
08 OFFICE, DOCTORPID: 44444Acct. #:
10/06 14:25
10 BUNDLE, SEPSISPID: 55555Acct. #:
10/06 14:30
12 TRANSFER, FLOORPID: 66666Acct. #:
= No Current Data CI = Contraindicated NA = Not Applicable
Report Run Date: 10/07/2010 09:59 1 of 2 Release 3.7.1
©2009 Philips VISICU - Confidential and ProprietaryPermission to reproduce is required. Philips VISICU retains all rights to the information provided provided, including, but not limited to, the right of distribution.
Vent BundleAlegent Health
Current Census as of: 10/07/2010 09:59
PHARMACY STAT
Evidence Based Care
(po0010)
PHYSICIAN ORDERS / PROGRESS NOTESCHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa
Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
DATE/ TIME ORDERS
DATE/TIME PROGRESS NOTES/CONSULTATION
VENTILATOR MANAGEMENT PROTOCOL Revised: 5/10 - Next Review: 5/11
Page 1 of 2 Ventilator Initiation
Mode: A/C. Rate: 10-12 bpm. VT = 5-8 ml/kg ideal body weight. PEEP: 5 cm H2O unless contraindicated (see right
side). FiO2: 100% - may wean for SaO2 ≥90% after initial
ABG. ABG 30 minutes after ventilator is initiated. Call
results to physician. Insert nasogastric/orogastric tube and place to low
intermittent suction. CXR after intubation if not already done. Daily CXR while intubated. Insert indwelling urinary catheter.
Ventilator Management Utilize SIMV with pressure support if patient’s clinical
status warrants. Adjust VT within the range of 5-8 ml/kg ideal body
weight. Adjust rate to maintain pH >7.3 and <7.5. Adjust PEEP up to 7.5 cm H2O for oxygenation
purposes. Pressure support may be adjusted to regulate
spontaneous VT to maintain an acceptable work of breathing – limit 20 cm H2O.
ABGs will be drawn on patients with a realized change in VE of 20% or more.
Physician must be notified of all patient status changes.
Ventilator Bundle Orders Elevate head of bed to 30 degrees. If head elevation
is contraindicated, place in reverse Trendelenburg if type of bed allows this position.
Oral care every 2 to 4 hours. Respiratory Therapy and Nursing to coordinate sedation vacation times with an extubation readiness assessment and weaning trials. If patient is on a neuromuscular blocking agent, turnoff the neuromuscular blocking agent at a minimum of every 24 hours ensure that a minimum of 4/4 twitch level is achieved. If this is not achieved, notify physician.
87018 v4 (Continued on Page 2)
Ideal Body Weight Calculations: IBW Male = 50 kg + (2.3 kg x Inches > 5 ft) IBW Female = 45.5 kg + (2.3 kg x Inches > 5 ft)
Contraindications to PEEP (Egans fundamentals of Respiratory Care) ►Increased Intracranial Pressure ►Pneumothorax that has not been treated ►Bronchopleural fistula ►Low Systolic blood pressure
PHARMACY STAT
Evidence Based Care
(po0010)
PHYSICIAN ORDERS / PROGRESS NOTESCHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT.
NKA Codeine Demerol Lidocaine Penicillin Other Aspirin Contrast Media Iodine Morphine Sulfa
Cephalosporin Darvocet Latex NSAID Tape Other MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”
DATE/ TIME ORDERS
DATE/TIME PROGRESS NOTES/CONSULTATION
VENTILATOR MANAGEMENT PROTOCOL Page 2 of 2
Stress Ulcer Medication Options
Famotidine (Pepcid) 20 mg IV every 12 hours. (Pharmacy to adjust dose for renal function.)
Esomeprazole (NexIUM) 40 mg dilution with 5 ml NS IV push over at least 3 minutes every 24 hours.
Sucralfate (Carafate) 1 gram Nasogastric, Orogastric or PEG tube every 6 hours. • Place Thrombosis Prophylaxis order (doc #83629) on chart for Physician review and consideration.
Ventilator Weaning Protocol • FiO2 will always be weaned to a minimum of 30%
unless there is a documented contraindication. • At 0700 or when clinically appropriate, mechanically
ventilated patients not meeting any of the exclusionary criteria will be placed on CPAP-5 cm with PS +5 cm H2O.
• Titrate FiO2 per O2 protocol. The trial should be continued for at least 2 hours and no less than 1 hour as indicated, or until any of the failure criteria are met. Patients failing the breathing trial should be put back on their previous mode of ventilation.
• Weaning parameters will be checked per protocol, and the results will be entered into the electronic medical record for physician review.
• When extubation criteria are met, notify physician. • Arterial blood gases will be obtained at the discretion of
the physician or respiratory therapist responsible for the spontaneous breathing trial.
Ordering MD/DO/NP/PA Signature Date Time
87018 v4
Warning StatementProton Pump Inhibitor interaction with PlaVIX Please assess patients on proton pump inhibitors and clopidogrel (PlaVIX) for possible drug interaction. If there is a high risk of GI bleed consider the use of pantoprazole (ProtoNIX) as an option for stress ulcer prevention.
Exclusionary Criteria for Ventilator weaning • Paralytics or deep sedation (modified Ramsay scale 4-
5). • Requiring >10 cm H2O PEEP or an FiO2>50% to keep
O2 sat >88%. • Hemodynamic instability. • Unstable cardiac rhythms. • Patient with respiratory rate >30/minute while receiving
a mandatory rate. • Minute volume of >15 L/minute. • Cardiogenic shock. • Acute Myocardial Infarction. • Lactic acidosis. Failure Criteria • Obvious respiratory distress (apnea, failure to trigger
vent, paradoxical respiratory movement, diaphoresis, agitation).
• Respiratory rate >32/minute for 10 minutes or longer. • Tachycardia >150/minute or an increase of >20% from
baseline for >10 minutes, or new onset arrhythmia. • Hypotension (SBP <90 mmHg) or a drop in blood
pressure of more than 20% from baseline. • Apnea beyond the first 5 minutes of the trial. • SaO2 <88% despite a FiO2 of >50%.
MODIFIED RAMSAY SCALE
1 Patient anxious, agitated, or restless
2 Patient cooperative, oriented, and tranquil
3 Patient responds to commands only
4 Patient responds to gentle shaking
5 Patient responds to noxious stimulus
6 Patient has no response to firm nail by pressure or other noxious stimuli
PHARMACY STAT
Evidence Based Care
(po0010) PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other
Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”DATE/ TIME ORDERS
DATE/TIME PROGRESS NOTES/CONSULTATION
SEDATION FOR MECHANICALLY VENTILATED PATIENTS
Revised: 5/10 - Next Review: 5/11 Page 1 of 2
Patient must be intubated and mechanically ventilated to use this order set. Maintain appropriate mandatory minimum minute ventilation.
Assure airway is secured and ventilator alarms are functioning.
Obtain baseline neurological assessment prior to initiating sedation.
Elevate head of bed 30 degrees. If head elevation is contraindicated, place in reverse Trendelenburg if type of bed allows this position.
Place Ventilator Management Protocol on chart for Physician review and consideration (Doc #87018).
Place Thrombosis Prophylaxis order (Doc #83629) on chart for Physician review and consideration.
Insert orogastric (preferred)/nasogastric tube unless otherwise directed and place to low intermittent suction if not contraindicated (e.g. facial trauma, bleeding risk or previous bariatric surgery).
Vital signs per nursing unit protocol and every 15 minutes if titrating propofol (Diprivan).
Continuous pulse oximetry.Measure and record weight now and every day.Pressure reduction sleep surface.Oral care every 2-4 hours.Assess Ramsay Score every 1 hour until desired effect,
then every 4 hours. Desired score: __________ (recommended score of 2-4).
Awaken patient daily to assess neurologic status. Coordinate sedation vacation with Respiratory Therapy for weaning trial.
Laboratory Obtain baseline serum triglyceride level prior to the
initiation of propofol (Diprivan).Obtain serum triglyceride every 72 hours while on
propofol (Diprivan) therapy times 3 draws.Titrate sedatives to maintain Ramsey score of 2.
Use the lowest possible dose that maintains desired sedation level, which may mean no sedatives at times.87017 v5 (Continued on Page 2)
MODIFIED RAMSAY SCALE1. Patient anxious, agitated, or restless 2. Patient cooperative, oriented, and tranquil 3. Patient responds to commands only 4. Patient responds to gentle shaking 5. Patient responds to noxious stimulus 6. Patient has no response to firm nail pressure or other
noxious stimuli
PHARMACY STAT
Evidence Based Care
(po0010) PHYSICIAN ORDERS / PROGRESS NOTES
CHECK ALLERGY. DOCUMENT TYPE OF REACTION IN NURSING ASSESSMENT. NKA Codeine Demerol Lidocaine Penicillin Other
Aspirin Contrast Media Iodine Morphine Sulfa Cephalosporin Darvocet Latex NSAID Tape Other
MEDICATION ORDERS WILL BE DISPENSED PER HOSPITAL DRUG FORMULARY SYSTEM UNLESS SPECIFICALLY STATED AS “NDPS” OR “DAW.”DATE/ TIME ORDERS
DATE/TIME PROGRESS NOTES/CONSULTATION
SEDATION FOR MECHANICALLY VENTILATED PATIENTS
Page 2 of 2
Sedative medication LORazepam (Ativan) mg IV push q.1h.
as needed for agitation (recommended range 1-3mg). OR
Propofol (Diprivan) initiate at 5 mcg/kg/minute. Titrate by 5-10 mcg/kg every 5-10 minutes until desired sedation level is achieved. (Maximum of 100 mcg/kg/minute). If BIS monitoring is ordered, titrate to BIS value of 40-60.
Analgesic medication Morphine Sulfate mg IV push q.1h. as needed for
pain (recommended range 1-5 mg. max dose 10 mg) OR
FentaNYL mcg IV q.1h. as needed for pain (recommended range 25-100 mcg).
Delirium Order Haloperidol (HALdol)
Bolus 1-5mg IV push. Assess agitation level after 20 minutes. If loading dose ineffective, increase dose by 1-5 mg every 20 minutes until desired effect, to a maximum of 15 mg.
Stress Ulcer Medication Options: Famotidine (Pepcid) 20 mg IV every 12 hours.
(Pharmacy to adjust dose for renal function.) Esomeprazole (NexIUM) 40 mg diluted with 5 ml
0.9% NaCl IV push over at least 3 minutes every 24 hours.
Sucralfate (Carafate) 1 gram nasogastric, orogastric or PEG tube every 6 hours.
Other .
___________________________________________ Ordering MD/DO/NP/PA Signature
Date ________________ Time
87017 v5
Consider re-evaluating the use of propofol (Diprivan) daily.
Consider using FentaNYL as a first option in the hemodynamically unstable patient.
Warning StatementProton Pump Inhibitor interaction with PlaVIX Due to literature reports of potential drug-drug interactions between PPIs and PlaVIX it is recommended to use a H2-Receptor Antagonist such as Pepcid (Famotidine), or Carafate for stress ulcer prophylaxis in patients who are receiving PlaVIX.
Alegent Health Daily ICU Interdisciplinary Plan of Care Date: ________ Nurse: _____________________ R.T.:______________________ Primary MD: _____________________ Consulting MD:___________________ Consulting MD:________________________ Admission weight_________ Height_________
Expected Length of Stay___________ Transfer Plan____________________ From__________ Return to_________ Independent Assistance
DNR status______________ Family Conference Date______________ #1 Family Contact________________
Patients #1 Safety Risk Today’s Goals Interventions 1.
2.
3.
4.
5.
Glucose Control Glucose on Arrival to ICU ___________ Last Glucose_________ Type of Coverage________________ Nutrition___________________
□ DVT prophylaxis □ Stress ulcer prevention □ PT/OT/speech consult □ Planned field trips
Core Measures □ PN □ CHF □ Acute MI □ Stroke
Vent Bundle: □ Head of Bed >30 □ Oral Care Q 2-4 hr □ Peptic Ulcer Prophylaxis □ DVT prophylaxis □ Sedation Vacation and readiness to wean every 24hours Time of Sedation Vacation_________ Outcome of Sedation Vacation______ Vent Day __________
Central Line Bundle: □ Insertion Date ______ □ Central line Day_____ □ Last Dressing Change date___________ □ Last Tubing Change____________ □ Central Line insertion check list used on Insertion
Alegent Health is a faith-based health ministry sponsored by Catholic Health Initiatives and Immanuel.
Photos left to right: IDCR at eFocus and IDCR at ICU bedside.
